Impact of antimalarial resistance and COVID-19 pandemic on malaria care among pregnant women in Northern Uganda (ERASE): protocol of a prospective observational study.

BACKGROUND: Uganda accounts for 5% of all malaria cases and deaths reported globally and, in endemic countries, pregnancy is a risk factor for both acquisition of P. falciparum infection and development of severe malaria. In recent years, malaria control has been threatened by COVID-19 pandemic and by the emergence, in Northern Uganda, of both resistance to artemisinin derivatives and to sulfadoxine-pyrimethamine. METHODS: In this facility-based, prospective, observational study, pregnant women will be recruited at antenatal-care visits and followed-up until delivery. Collected data will explore the incidence of asymptomatic parasitemia and malaria-related outcomes, as well as the attitudes towards malaria prevention, administration of intermittent preventive treatment, healthcare seeking behavior and use of insecticide-treated nets. A subpopulation of women diagnosed with malaria will be recruited and their blood samples will be analyzed for detection of genetic markers of resistance to artemisinin derivatives and sulfadoxine-pyrimethamine. Also, to investigate the impact of COVID-19 on malaria care among pregnant women, a retrospective, interrupted-time series will be conducted on at the study sites for the period January 2018 to December 2021. DISCUSSION: The present study will explore the impact of COVID-19 pandemic on incidence of malaria and malaria-related adverse outcomes, along with the prevalence of resistance to artemisinin derivatives and to sulfadoxine-pyrimethamine. To our knowledge, this is the first study aiming to explore the combined effect of these factors on a cohort of pregnant women. TRIAL REGISTRATION: This study has been registered on the ClinicalTrials.gov public website on 26th April, 2022. CLINICALTRIALS: gov Identifier: NCT05348746.

Availability, utilisation and quality of maternal and neonatal health care services in Karamoja region, Uganda: a health facility-based survey.

BACKGROUND: Maternal mortality is persistently high in Uganda. Access to quality emergency obstetrics care (EmOC) is fundamental to reducing maternal and newborn deaths and is a possible way of achieving the target of the fifth millennium development goal. Karamoja region in north-eastern Uganda has consistently demonstrated the nation's lowest scores on key development and health indicators and presents a substantial challenge to Uganda's stability and poverty eradication ambitions. The objectives of this study were: to establish the availability of maternal and neonatal healthcare services at different levels of health units; to assess their utilisation; and to determine the quality of services provided. METHODS: A cross sectional study of all health facilities in Napak and Moroto districts was conducted in 2010. Data were collected by reviewing clinical records and registers, interviewing staff and women attending antenatal and postnatal clinics, and by observation. Data were summarized using frequencies and percentages and EmOC indicators were calculated. RESULTS: There were gaps in the availability of essential infrastructure, equipment, supplies, drugs and staff for maternal and neonatal care particularly at health centres (HCs). Utilisation of the available antenatal, intrapartum, and postnatal care services was low. In addition, there were gaps in the quality of care received across these services. Two hospitals, each located in the study districts, qualified as comprehensive EmOC facilities. The number of EmOC facilities per 500,000 population was 3.7. None of the HCs met the criteria for basic EmOC. Assisted vaginal delivery and removal of retained products were the most frequently missing signal functions. Direct obstetric case fatality rate was 3%, the met need for EmOC was 9.9%, and 1.7% of expected deliveries were carried out by caesarean section. CONCLUSIONS: To reduce maternal and newborn morbidity and mortality in Karamoja region, there is a need to increase the availability and the accessibility of skilled birth care, address the low utilisation of maternity services and improve the quality of care rendered. There is also a need to improve the availability and accessibility of EmOC services, with particular attention to basic EmOC.

A qualitative study on barriers to utilisation of institutional delivery services in Moroto and Napak districts, Uganda: implications for programming.

BACKGROUND: Skilled attendance at delivery is critical in prevention of maternal deaths. However, many women in low- and middle-income countries still deliver without skilled assistance. This study was carried out to identify perceived barriers to utilisation of institutional delivery in two districts in Karamoja, Uganda. METHODS: Data were collected through participatory rural appraisal (PRA) with 887 participants (459 women and 428 men) in 20 villages in Moroto and Napak districts. Data were analysed using deductive content analysis. Notes taken during PRA session were edited, triangulated and coded according to recurring issues. Additionally, participants used matrix ranking to express their perceived relative significance of the barriers identified. RESULTS: The main barriers to utilisation of maternal health services were perceived to be: insecurity, poverty, socio-cultural factors, long distances to health facilities, lack of food at home and at health facilities, lack of supplies, drugs and basic infrastructure at health facilities, poor quality of care at health facilities, lack of participation in planning for health services and the ready availability of traditional birth attendants (TBAs). Factors related to economic and physical inaccessibility and lack of infrastructure, drugs and supplies at health facilities were highly ranked barriers to utilisation of institutional delivery. CONCLUSION: A comprehensive approach to increasing the utilisation of maternal health care services in Karamoja is needed. This should tackle both demand and supply side barriers using a multi-sectorial approach since the main barriers are outside the scope of the health sector. TBAs are still active in Karamoja and their role and influence on maternal health in this region cannot be ignored. A model for collaboration between skilled health workers and TBAs in order to increase institutional deliveries is needed.

COVID Perceptions among Pregnant Women Living in a Malaria Hyperendemic Rural Region in Uganda: A Cross-Sectional Study.

Both SARS-CoV2 and Plasmodium falciparum infection during pregnancy increases the risk for adverse maternal and fetal outcomes, including abortion, severe disease, and death. Indeed, although malaria and COVID-19 show an overlapping clinical presentation, they require a profoundly different approach. The aim of this study was to explore COVID-19 awareness among pregnant women living in a P. falciparum hyperendemic region in rural Uganda. This cross-sectional, prospective study was conducted in one Hospital and two Health Centers (HC) in Lango region, Uganda, from July 14, 2022, to March 14, 2023. Data about demographics, COVID-19 history, and COVID-19 and malaria perceptions were collected using RedCap mobile app platform. Study endpoint was a context-specific COVID-19 awareness score, accounting for the most common disease misconceptions. Association between study variables and good COVID-19 awareness was assessed by χ2 and t test, as appropriate, and variables found to be statistically significant were further explored in multivariate logistic regression analysis. A total of 888 pregnant women were recruited. Median age was 24 (interquartile range: 20-29) years, whereas 79% (n = 704) attained only primary education and 66.6% (n = 591) were used in agriculture. SARS-CoV2 vaccination rate was 92%. In multivariate analysis (Table 3), variables associated with high COVID knowledge were presenting at antenatal care visit in Atipe HC (adjusted odds ratio [aOR]: 8.1, 95% CI: 4.1-16.48) having a previous good knowledge about malaria (aOR: 1.76, 95% CI: 1.21-2.56). Among pregnant women living in rural Uganda, COVID-19 awareness relies on the overall educational level, malaria knowledge and reference HC. Among pregnant women living in P. falciparum endemic areas, community-level malaria awareness might guide educational interventions during future pandemics.

Impact of the COVID-19 pandemic on malaria in pregnancy indicators in Northern Uganda: a joinpoint regression analysis.

BACKGROUND: Pregnancy is both a risk factor for P. falciparum infection and development of severe malaria. In low- and middle-income countries, the COVID-19 pandemic severely impacted health systems, including utilization of maternal services. This study aimed to assess trends in delivering malaria in pregnancy-related health-care services before and during COVID-19 in Northern Uganda. METHODS: An interrupted time-series study comparing pre-COVID-19 (January 2018 to April 2020) and COVID-19 (May to December 2021) periods, based on the date the first COVID case was detected. The study involved 30 health facilities in Northern Uganda with 22,650 estimated pregnancies per year, 14% of which took place in hospital. Monthly data were sourced from District routinely collected indicators. Trends were analyzed by joinpoint regression models. RESULTS: From the onset of the COVID pandemic in Uganda (May 2020), we found a significant reduction in the number of women accessing a fourth antenatal care visit (from APC + 183.5 to + 4.98; p < 0.001) and taking at least three doses of intermittent preventive treatment in pregnancy (IPTp, from APC + 84.28 to -63.12; p < 0.001). However, we found no significant change in the trend of the total number of pregnant women managed as outpatients or hospitalized for malaria, as well as in the number of women attending their first antenatal visit and in the number of institutional deliveries. CONCLUSIONS: In our study, the COVID-19 pandemic significantly reduced access to ANC visits and IPTp uptake. However, the healthcare system maintained its capacity for managing malaria cases, first antenatal visits, and institutional deliveries.Trial registration: This study has been registered on the ClinicalTrials.gov public website on 26 April 2022. ClinicalTrials.gov Identifier: NCT05348746.

An integrated hospital-district performance evaluation for communicable diseases in low-and middle-income countries: Evidence from a pilot in three sub-Saharan countries.

INTRODUCTION: The last two decades saw an extensive effort to design, develop and implement integrated and multidimensional healthcare evaluation systems in high-income countries. However, in low- and middle-income countries, few experiences of such systems implementation have been reported in the scientific literature. We developed and piloted an innovative evaluation tool to assess the performance of health services provision for communicable diseases in three sub-Saharan African countries. MATERIAL AND METHODS: A total of 42 indicators, 14 per each communicable disease care pathway, were developed. A sub-set of 23 indicators was included in the evaluation process. The communicable diseases care pathways were developed for Tuberculosis, Gastroenteritis, and HIV/AIDS, including indicators grouped in four care phases: prevention (or screening), diagnosis, treatment, and outcome. All indicators were calculated for the period 2017-2019, while performance evaluation was performed for the year 2019. The analysis involved four health districts and their relative hospitals in Ethiopia, Tanzania, and Uganda. RESULTS: Substantial variability was observed over time and across the four different districts. In the Tuberculosis pathway, the majority of indicators scored below the standards and below-average performance was mainly reported for prevention and diagnosis phases. Along the Gastroenteritis pathway, excellent performance was instead evaluated for most indicators and the highest scores were reported in prevention and treatment phases. The HIV/AIDS pathway indicators related to screening and outcome phases were below the average score, while good or excellent performance was registered within the treatment phase. CONCLUSIONS: The bottom-up approach and stakeholders' engagement increased local ownership of the process and the likelihood that findings will inform health services performance and quality of care. Despite the intrinsic limitations of data sources, this framework may contribute to promoting good governance, performance evaluation, outcomes measurement and accountability in settings characterised by multiple healthcare service providers.

Changing the role of traditional birth attendants in Yirol West County, South Sudan.

Effective from May 2014, community-based traditional birth attendants (TBAs) in Yirol West County, South Sudan, were directed to start referring all women in labour to health facilities for childbirth instead of assisting them in the villages. This study aimed to understand the degree of integration of TBAs in the health system, to reveal the factors influencing the integration, and to explore the perceived solutions to the challenges faced by TBAs. A qualitative study utilising 11 focus group discussions with TBAs, 6 focus group discussions with women, and 18 key informant interviews with members of village health committees, staff of health facilities, and staff of the County Health Department was conducted. Data were analysed using qualitative content analysis. The study found that many TBAs were referring women to health facilities for delivery, but some were still attending to deliveries at home. Facilitators of the adoption of the new role by TBAs were: acceptance of the new TBAs' role by the community, women and TBAs, perceptions about institutional childbirth and risks of home childbirth, personal commitment and motivation by some TBAs, a good working relationship between community-based TBAs and health facility staff, availability of incentives for women at health facilities, and training of TBAs. Challenges of integrating TBAs in the health system included, among others, communication problems between TBAs and health care facilities, delays in seeking care by women, insecurity, lack of materials and supplies for TBAs, health system constraints, insufficient incentives for TBAs, long distances to health facilities and transportation problems. This study has revealed encouraging developments in TBAs' integration in the formal health system in Yirol West. However, there is need to address the challenges faced by TBAs in assuming their new role in order to sustain the integration.